A Rare Case of an Asymmetric Overgrowth Syndrome in a Kenyan African Child: A Case Report and Review of Literature.

Body overgrowth may be generalized or may affect certain areas. We present a seven-year-old African male with progressive, asymmetric, postnatal overgrowth of the left side of his face and left upper limb. The impression of proteus syndrome (PS) was made based on established clinical diagnostic criteria presented in the literature. Our objective is to highlight the diagnosis based on clinical features, investigations, and a multidisciplinary approach to the management of proteus syndrome.

Prediction modelling of inpatient neonatal mortality in high-mortality settings.

OBJECTIVE: Prognostic models aid clinical decision making and evaluation of hospital performance. Existing neonatal prognostic models typically use physiological measures that are often not available, such as pulse oximetry values, in routine practice in low-resource settings. We aimed to develop and validate two novel models to predict all cause in-hospital mortality following neonatal unit admission in a low-resource, high-mortality setting. STUDY DESIGN AND SETTING: We used basic, routine clinical data recorded by duty clinicians at the time of admission to derive (n=5427) and validate (n=1627) two novel models to predict in-hospital mortality. The Neonatal Essential Treatment Score (NETS) included treatments prescribed at the time of admission while the Score for Essential Neonatal Symptoms and Signs (SENSS) used basic clinical signs. Logistic regression was used, and performance was evaluated using discrimination and calibration. RESULTS: At derivation, c-statistic (discrimination) for NETS was 0.92 (95% CI 0.90 to 0.93) and that for SENSS was 0.91 (95% CI 0.89 to 0.93). At external (temporal) validation, NETS had a c-statistic of 0.89 (95% CI 0.86 to 0.92) and SENSS 0.89 (95% CI 0.84 to 0.93). The calibration intercept for NETS was -0.72 (95% CI -0.96 to -0.49) and that for SENSS was -0.33 (95% CI -0.56 to -0.11). CONCLUSION: Using routine neonatal data in a low-resource setting, we found that it is possible to predict in-hospital mortality using either treatments or signs and symptoms. Further validation of these models may support their use in treatment decisions and for case-mix adjustment to help understand performance variation across hospitals.

Competing risk survival analysis of time to in-hospital death or discharge in a large urban neonatal unit in Kenya.

Background: Clinical outcomes data are a crucial component of efforts to improve health systems globally. Strengthening of these health systems is essential if the Sustainable Development Goals (SDG) are to be achieved. Target 3.2 of SDG Goal 3 is to end preventable deaths and reduce neonatal mortality to 12 per 1,000 or lower by 2030. There is a paucity of data on neonatal in-hospital mortality in Kenya that is poorly captured in the existing health information system. Better measurement of neonatal mortality in facilities may help promote improvements in the quality of health care that will be important to achieving SDG 3 in countries such as Kenya. Methods: This was a cohort study using routinely collected data from a large urban neonatal unit in Nairobi, Kenya. All the patients admitted to the unit between April 2014 to December 2015 were included. Clinical characteristics are summarised descriptively, while the competing risk method was used to estimate the probability of in-hospital mortality considering discharge alive as the competing risk. Results: A total of 9,115 patients were included. Most were males (966/9115, 55%) and the majority (6287/9115, 69%) had normal birthweight (2.5 to 4 kg). Median length of stay was 2 days (range, 0 to 98 days) while crude mortality was 9.2% (839/9115). The probability of in-hospital death was higher than discharge alive for birthweight less than 1.5 kg with the transition to higher probability of discharge alive observed after the first week in birthweight 1.5 to <2 kg. Conclusions: These prognostic data may inform decision making, e.g. in the organisation of neonatal in-patient service delivery to improve the quality of care. More of such data are therefore required from neonatal units in Kenya and other low resources settings especially as more advanced neonatal care is scaled up.

Using a common data platform to facilitate audit and feedback on the quality of hospital care provided to sick newborns in Kenya.

Essential interventions to reduce neonatal deaths that can be effectively delivered in hospitals have been identified. Improving information systems may support routine monitoring of the delivery of these interventions and outcomes at scale. We used cycles of audit and feedback (A&F) coupled with the use of a standardised newborn admission record (NAR) form to explore the potential for creating a common inpatient neonatal data platform and illustrate its potential for monitoring prescribing accuracy. Revised NARs were introduced in a high volume, neonatal unit in Kenya together with 13 A&F meetings over a period of 3 years from January 2014 to November 2016. Data were abstracted from medical records for 15 months before introduction of the revised NAR and A&F and during the 3 years of A&F. We calculated, for each patient, the percentage of documented items from among the total recommended for documentation and trends calculated over time. Gentamicin prescribing accuracy was also tracked over time. Records were examined for 827 and 7336 patients in the pre-A&F and post-A&F periods, respectively. Documentation scores improved overall. Documentation of gestational age improved from <15% in 2014 to >75% in 2016. For five recommended items, including temperature, documentation remained <50%. 16.7% (n=1367; 95% CI 15.9 to 17.6) of the admitted babies had a diagnosis of neonatal sepsis needing antibiotic treatment. In this group, dosing accuracy of gentamicin improved over time for those under 2 kg from 60% (95%36.1 to 80.1) in 2013 to 83% (95% CI 69.2 to 92.3) in 2016. We report that it is possible to improve routine data collection in neonatal units using a standardised neonatal record linked to relatively basic electronic data collection tools and cycles of A&F. This can be useful in identifying potential gaps in care and tracking outcomes with an aim of improving the quality of care.

Pulse oximetry values of neonates admitted for care and receiving routine oxygen therapy at a resource-limited hospital in Kenya.

AIM: There are 2.7 million neonatal deaths annually, 75% of which occur in sub-Saharan Africa and South Asia. Effective treatment of hypoxaemia through tailored oxygen therapy could reduce neonatal mortality and prevent oxygen toxicity. METHODS: We undertook a two-part prospective study of neonates admitted to a neonatal unit in Nairobi, Kenya, between January and December 2015. We determined the prevalence of hypoxaemia and explored associations of clinical risk factors and signs of respiratory distress with hypoxaemia and mortality. After staff training on oxygen saturation (SpO2 ) target ranges, we enrolled a consecutive sample of neonates admitted for oxygen and measured SpO2 at 0, 6, 12, 18 and 24 h post-admission. We estimated the proportion of neonates outside the target range (≥34 weeks: ≥92%; <34 weeks: 89-93%) with 95% confidence intervals (CIs). RESULTS: A total of 477 neonates were enrolled. Prevalence of hypoxaemia was 29.2%. Retractions (odds ratio (OR) 2.83, 95% CI 1.47-5.47), nasal flaring (OR 2.68, 95% CI 1.51-4.75), and grunting (OR 2.47, 95% CI 1.27-4.80) were significantly associated with hypoxaemia. Nasal flaring (OR 2.85, 95% CI 1.25-6.54), and hypoxaemia (OR 3.06, 95% CI 1.54-6.07) were significantly associated with mortality; 64% of neonates receiving oxygen were out of range at ≥2 time points and 43% at ≥3 time points. CONCLUSION: There is a high prevalence of hypoxaemia at admission and a strong association between hypoxaemia and mortality in this Kenyan neonatal unit. Many neonates had out of range SpO2 values while receiving oxygen. Further research is needed to test strategies aimed at improving the accuracy of oxygen provision in low-resource settings.

Oxygen saturation ranges for healthy newborns within 24†hours at 1800†m.

There are minimal data to define normal oxygen saturation (SpO2) levels for infants within the first 24 hours of life and even fewer data generalisable to the 7% of the global population that resides at an altitude of >1500 m. The aim of this study was to establish the reference range for SpO2 in healthy term and preterm neonates within 24 hours in Nairobi, Kenya, located at 1800 m. A random sample of clinically well infants had SpO2 measured once in the first 24 hours. A total of 555 infants were enrolled. The 5th-95th percentile range for preductal and postductal SpO2 was 89%-97% for the term and normal birthweight groups, and 90%-98% for the preterm and low birthweight (LBW) groups. This may suggest that 89% and 97% are reasonable SpO2 bounds for well term, preterm and LBW infants within 24 hours at an altitude of 1800 m.